1 Assistant Lecturer of Vascular Surgery, Zagazig UniversityComparison Between Conventional Surgery and Endovenous Laser Ablation in Management of Primary Varicose Vein By Dr. Mohamed H. Zidan Assistant Lecturer of Vascular Surgery, Zagazig University

2 Introduction In recent past classical surgical method of ligation and stripping of incompetent saphenous vein was a gold standard in the treatment of lower extremity varicose veins However, during last decade minimal invasive techniques were introduced to treat the incompetent saphenous vein and varicosities with incompetent great saphenous vein (GSV) or small saphenous vein (SSV McBride, KD. , Surgeon : J Royal Colleges surg. Edinburgh 2011;9(3):

3 Reduced postoperative pain, peri-saphenous vein hematoma Endovenous laser ablation (EVLA) is one of them and it has been used as minimally invasive replacement to classical surgical EVLA may offer: Reduced postoperative pain, peri-saphenous vein hematoma Decreased rate of wound infection Reduce time of operation Rapid return to work No scar McBride, KD. , Surgeon : J Royal Colleges surg. Edinburgh 2011;9(3):

4 Patients & Methods This is a prospective randomized clinical trial with two treatment arms of 50 limbs each Group I: Received conventional high ligation and stripping surgery for GSV or SSV insufficiency Group II: Received EVLA using endotherme 1470 (Osoris), manufactured by LSO medical, France This is done duplex-guided

8 EVLA Technique Tumescent solution injection in saphenous compartmentStart LASER activation while pulling back fiber at a steady speed

9 EVLA Technique Ingection of superfacial varicosities & incompetent perforators Elastic bandage is applied at end of procedure

10 Follow up For both groups:Duplex ultrasound was done at the end of the procedure, at 1st month, 6 months and one year Clinical examination at regular visits for any complications or recurrence Patient satisfaction evaluation

11 Duplex US Follow Up Immediate post-operative After 6 monthGSV Immediate post-operative After 6 month After one year SFJ GSV CFV CFV SFJ GSV CFV CFV

12 Follow up Primary end points Secondary end point Closure ratePost-operative complication (brusing ,hematoma , phelebitis , skin burn …ect) Time to return to normal activity Pain scores (visual analog scale (VAS) Quality of life questionaire(QOL) Venous Clinical Severity Score(VCSS) Chronic venous insufficiency questionnaire (CIVIQ) Secondary end point Recurrence within 2 years

13 Endotherme 1470 (Osoris)

14 Laser Fiber Encapsulated tip Smooth Non traumaticRinglight radial firing fiber

15 Laser Fiber Radial emission Homogenous destruction of the vein wallLong-term occlusion Reduce risk of damage to surrounding tissues F Pannier et al , Phlebology 2011;26:35–39

16 RESULTS

17 Results Group I (Surgery) Group II (EVLA) 50 limbs in 32 patients50 limbs had GSV incompetence 5 limbs had GSV & SSV incompetence Group II (EVLA) 50 limbs in 32 patients 2 limbs had GSV and SSV incompetence 5 limbs had Sup.ASV incompetence

18 EVLA(n=32) Surgery(n=44) 32 (16-65) 34.5 (16-65) Age (Mean) 8(25%) 24(75%) 20(45%) 24(55%) Sex Male Female 21.4(20-23) 21.6(19-23) BMI (Mean) 14(44%) 18(56%) 38(86%) 6(14%) Unilateral Bilateral 13(26%) 37(74%) 24(48%) 26(52%) CEAP C3 C4 10.2( mm) 10.6( mm) GSV diameter (Mean) 50 Pain 37 26 Swelling 47 45 Heaviness 32 23 Cramps

19 EVLA Group Numbers Variables 50 Limbs No. 90 – 150 min.Duration of operation 45 – 67 cm. Length of GSV treated 1 Difficult access (cutdown) 80-120 LEED(Energy Delivered) J/cm²

20 Post-operative ComplicationsP-value χ2 EVLA Surgery Variables 0.003** 8.7 8(16%) Phlebitis 0.004** 8.31 2(4%) 12(24%) Bruises Hematoma 0.15 NS 2.04 Superficial burn <0.001** 17.42 19(38%) Transient Parasthesia 0.14 NS 2.17 6(19%) 2(4.5%) Spinal headache 0.17NS 1.90 1(2%) 4(8%) Skin pigmentation DVT

21 Pain scores (visual analog scale (VAS)P-value MW EVLA Surgery Variables 0.06NS 1.88 5.6(2-8) 5.2(3-8) VAS(Pre-op) <0.001** 5.66 0.76(0-2) 1.96(1-4) VAS(1st week) 4.44 0.22(0-2) VAS(1 month) Time to return to normal daily activity P-value t EVLA Surgery Variables <0.001** 9.3 7.7(7-10) 16(14-30) Time to return to work(Day) (Mean)

22 Quality of life questionaire(QOL)1-Venous Clinical Severity Score(VCSS) P-value t EVLA Surgery Variables 0.86NS 0.17 9.7(5-14) 9.6(5-13) VCSS(Pre-op) <0.001** 3.3 3.9(2-7) 4.8(3-8) VCSS(6 month) 2-Chronic venous insufficiency questionnaire (CIVIQ) P-value t EVLA Surgery Variables 0.30 NS 1.04 49.5(37-68) 48(38-61) CIVIQ(Pre-op) <0.001** 14.15 21.6(14-32) 36.3(27-47) CIVIQ(6 month)

23 Recurrence(After one year)Closure rate P-value χ2 EVLA Surgery Variables --- 50(100%) Abolished GSV or SSV Recurrence(After one year) P-value χ2 EVLA Surgery Variables 0.31 NS 1.04 1(2%) 3(6%) Recurrence

24 CONCLUSION

25 Conclusion According to obtained results; endovenous laser ablation (EVLA) enables patients a better recovery in terms of : Significantly lower post treatment pain Faster return to everyday activities Lower incidence of complications

26 Conclusion Postoperative patient comfort and outcome of EVLA in short term are not inferior to those after stripping and ligation of the saphenofemoral confluence

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